Flexible transoral endoscopic gastroesophageal flap valve restoration device and method

ABSTRACT

A transoral gastroesophageal flap valve restoration device has sufficient flexibility and dimension to be passed through the mouth, throat, and esophagus of a patient into the patient&#39;s stomach. The device includes a first member and a second member hingedly coupled to the first member. The first and second members are configured to flex in a direction to follow the esophageal path into the stomach and to be substantially rigid when forming the restored gastroesophageal flap valve.

This application is a continuation of application Ser. No. 11/893,549,filed on Aug. 15, 2001, which is a continuation of application Ser. No.11/001,666, filed on Nov. 30, 2004, which is related to application Ser.No. 11/001,681, filed on Nov. 30, 2004. The entire disclosures of whichare hereby incorporated by reference for all purposes.

FIELD OF THE INVENTION

The present invention generally relates to devices for treatinggastroesophageal reflux disease. The present invention more particularlyrelates to such devices which are flexible enough for passage into thestomach while being capable of being made selectively rigid for forminga gastroesophageal flap.

BACKGROUND

Gastroesophageal reflux disease (GERD) is a chronic condition caused bythe failure of the anti-reflux barrier located at the gastroesophagealjunction to keep the contents of the stomach from splashing into theesophagus. The splashing is known as gastroesophageal reflux. Thestomach acid is designed to digest meat, and will digest esophagealtissue when persistently splashed into the esophagus.

A principal reason for regurgitation associated with GERD is themechanical failure of a deteriorated gastroesophageal flap to close andseal against high pressure in the stomach. Due to reasons includinglifestyle, a Grade I normal gastroesophageal flap may deteriorate into amalfunctioning Grade III or absent valve Grade IV gastroesophageal flap.With a deteriorated gastroesophageal flap, the stomach contents are morelikely to be regurgitated into the esophagus, the mouth, and even thelungs. The regurgitation is referred to as “heartburn” because the mostcommon symptom is a burning discomfort in the chest under thebreastbone. Burning discomfort in the chest and regurgitation (burpingup) of sour-tasting gastric juice into the mouth are classic symptoms ofgastroesophageal reflux disease (GERD). When stomach acid isregurgitated into the esophagus, it is usually cleared quickly byesophageal contractions. Heartburn (backwashing of stomach acid and bileonto the esophagus) results when stomach acid is frequently regurgitatedinto the esophagus and the esophageal wall is inflamed.

Complications develop for some people who have GERD. Esophagitis(inflammation of the esophagus) with erosions and ulcerations (breaks inthe lining of the esophagus) can occur from repeated and prolonged acidexposure. If these breaks are deep, bleeding or scarring of theesophagus with formation of a stricture (narrowing of the esophagus) canoccur. If the esophagus narrows significantly, then food sticks in theesophagus and the symptom is known as dysphagia. GERD has been shown tobe one of the most important risk factors for the development ofesophageal adenocarcinoma. In a subset of people who have severe GERD,if acid exposure continues, the injured squamous lining is replaced by aprecancerous lining (called Barrett's Esophagus) in which a cancerousesophageal adenocarcinoma can develop.

Other complications of GERD may not appear to be related to esophagealdisease at all. Some people with GERD may develop recurrent pneumonia(lung infection), asthma (wheezing), or a chronic cough from acidbacking up into the esophagus and all the way up through the upperesophageal sphincter into the lungs. In many instances, this occurs atnight, while the person is in a supine position and sleeping.Occasionally, a person with severe GERD will be awakened from sleep witha choking sensation. Hoarseness can also occur due to acid reaching thevocal cords, causing a chronic inflammation or injury.

GERD never improves without intervention. Life style changes combinedwith both medical and surgical treatments exist for GERD. Medicaltherapies include antacids and proton pump inhibitors. However, themedical therapies only mask the reflux. Patients still get reflux andperhaps emphysema because of particles refluxed into the lungs.Barrett's esophagus results in about 10% of the GERD cases. Theesophageal epithelium changes into tissue that tends to become cancerousfrom repeated acid washing despite the medication.

Several open laparotomy and laproscopic surgical procedures areavailable for treating GERD. One surgical approach is the Nissenfundoplication. The Nissen approach typically involves a 360° wrap ofthe fundus around the gastroesophageal junction. The procedure has ahigh incidence of postoperative complications. The Nissen approachcreates a 360° moveable flap without a fixed portion. Hence, Nissen doesnot restore the normal movable flap. The patient cannot burp because thefundus was used to make the repair, and may frequently experiencedysphagia. Another surgical approach to treating GERD is the Belsey MarkIV (Belsey) fundoplication. The Belsey procedure involves creating avalve by suturing a portion of the stomach to an anterior surface of theesophagus. It reduces some of the postoperative complicationsencountered with the Nissen fundoplication, but still does not restorethe normal movable flap. None of these procedures fully restores thenormal anatomical anatomy or produces a normally functioninggastroesophageal junction. Another surgical approach is the Hill repair.In the Hill repair, the gastroesophageal junction is anchored to theposterior abdominal areas, and a 180° valve is created by a system ofsutures. The Hill procedure restores the moveable flap, the cardiacnotch and the Angle of His. However, all of these surgical proceduresare very invasive, regardless of whether done as a laproscopic or anopen procedure.

New, less surgically invasive approaches to treating GERD involvetransoral endoscopic procedures. One procedure contemplates a machinedevice with robotic arms that is inserted transorally into the stomach.While observing through an endoscope, an endoscopist guides the machinewithin the stomach to engage a portion of the fundus with acorkscrew-like device on one arm. The arm then pulls on the engagedportion to create a fold of tissue or radial plication at thegastroesophageal junction. Another arm of the machine pinches the excesstissue together and fastens the excess tissue with one pre-tied implant.This procedure does not restore normal anatomy. The fold created doesnot have anything in common with a valve. In fact, the direction of theradial fold prevents the fold or plication from acting as a flap of avalve.

Another transoral procedure contemplates making a fold of fundus tissuenear the deteriorated gastroesophageal flap to recreate the loweresophageal sphincter (LES). The procedure requires placing multipleU-shaped tissue clips around the folded fundus to hold it in shape andin place.

This and the previously discussed procedure are both highly dependent onthe skill, experience, aggressiveness, and courage of the endoscopist.In addition, these and other procedures may involve esophageal tissue inthe repair. Esophageal tissue is fragile and weak. Involvement ofesophageal tissue in the repair of a gastroesophageal flap valve posesunnecessary risks to the patient.

A new and improved device and method for restoration of agastroesophageal flap valve is fully disclosed in U.S. Pat. No.6,790,214, issued Sep. 14, 2004, for TRANSORAL ENDOSCOPICGASTROESOPHAGEAL FLAP VALVE RESTORATION DEVICE, ASSEMBLY, SYSTEM ANDMETHOD, which patent is assigned to the assignee of this invention, andis incorporated herein by reference. That apparatus and method providestransoral endoscopic gastroesophageal flap valve restoration. Alongitudinal member arranged for transoral placement into a stomachcarries a tissue shaper that non-invasively grips and shapes stomachtissue. A tissue fixation device is then deployed to maintain the shapedstomach tissue in a shape approximating a gastroesophageal flap.

Whenever stomach tissue is to be transorally shaped as, for example, bythe improved device last mentioned above, it is necessary to feed thedevice down the esophageal passage including the mouth, throat, andesophagus and into the stomach. Unfortunately, the throat and esophagusare capable of expanding to only a diameter of about two centimeters (2cm) without damage. Further, the back of throat defines a radius ofapproximately only 4.4 cm in the average adult. Hence, for any kind ofdevice to be guided down into the stomach, the device must have amaximum perimeter of no more than about 6.28 cm (2 cm×π) and be flexibleenough to bend through the radius of 4.4 cm defined by the back of thethroat. While being flexible enough to travel down the throat andesophagus, the device must also be rigid enough to shape the stomachtissue necessary to form the gastroesophageal flap. The presentinvention addresses these issues.

SUMMARY

The invention provides a transoral gastroesophageal flap valverestoration device comprising a first member, and a second memberhingedly coupled to the first member. The first and second members arearranged for esophageal passage into a stomach to receive stomach tissuethere between and to form a flap of a gastroesophageal flap valve. Thefirst and second members are configured to flex in a direction to followthe esophageal path into the stomach and to be substantially rigid whenreceiving the stomach tissue there between to form the flap of thegastroesophageal flap valve.

The invention further provides an assembly for restoring agastroesophageal flap valve comprising a longitudinal member having anend arranged for placement in a stomach, and a transoralgastroesophageal flap valve restoration device carried at the end of thelongitudinal member including a first member and a second memberhingedly coupled to the first member. The first and second members arearranged for esophageal passage into a stomach to receive stomach tissuethere between and to form a flap of a gastroesophageal flap valve. Thefirst and second members are also configured to flex in a direction tofollow the esophageal path into the stomach but to also be substantiallyrigid when receiving the stomach tissue there between and forming theflap of the gastroesophageal flap valve.

According to another embodiment, the invention provides a transoralgastroesophageal flap valve restoration device that is selectivelyflexible during mouth, throat, and esophagus passage into a stomach, andselectively comparatively rigid during folding of stomach tissue into arestored gastroesophageal flap.

The invention further provides a method of restoring a gastroesophagealflap valve. The method comprises providing a transoral gastroesophagealflap valve restoration device comprising a first member and a secondmember hingedly coupled to the first member, the first and secondmembers being flexible for esophageal passage into a stomach andsubstantially rigid to receive stomach tissue there between to form aflap of a gastroesophageal flap valve when in a second orientation. Themethod further comprises feeding the device down the esophagus into thestomach with the device in a flexible condition, rendering the devicesubstantially rigid, and pulling stomach tissue between the first andsecond members to form the flap of the gastroesophageal flap valve.

The invention still further provides a method of restoring agastroesophageal flap valve comprising the steps of providing atransoral gastroesophageal flap valve restoration device arranged foresophageal passage into a stomach when in a substantially flexiblecondition and to receive stomach tissue to form a flap of agastroesophageal flap valve when in a substantially rigid condition. Themethod further comprises feeding the device down the esophagus into thestomach with the device in the substantially flexible condition,rendering the device into the substantially rigid condition, and pullingstomach tissue into the device to form the flap of the gastroesophagealflap valve.

BRIEF DESCRIPTION OF THE DRAWINGS

The features of the present invention which are believed to be novel areset forth with particularity in the appended claims. The invention,together with further objects and advantages thereof, may best beunderstood by making reference to the following description taken inconjunction with the accompanying drawings, in the several figures ofwhich like referenced numerals identify like elements, and wherein:

FIG. 1 is a front cross-sectional view of theesophageal-gastro-intestinal tract from a lower portion of the esophagusto the duodenum;

FIG. 2 is a front cross-sectional view of theesophageal-gastro-intestinal tract illustrating a Grade I normalappearance movable flap of the gastroesophageal flap valve (in dashedlines) and a Grade III reflux appearance gastroesophageal flap of thegastroesophageal flap valve (in solid lines);

FIG. 3 is a simplified side view of a device according to an embodimentof the invention being fed down an esophageal passage of a patient;

FIG. 4 is a side view of the device of FIG. 3;

FIG. 5 is a cross-sectional view taken along lines 5-5 of FIG. 4;

FIG. 6 is a cross-sectional view illustrating the change in thecross-section of FIG. 5 when the device is flexed;

FIG. 7 is a side view of the device of FIG. 3 while restoring agastroesophageal flap valve according to an embodiment of the invention;

FIG. 8 is a top view of the distal end of the device of FIG. 3;

FIG. 9 is a perspective view of another device according to anotherembodiment of the invention;

FIG. 10 is a perspective view of the device of FIG. 3 while restoring agastroesophageal flap valve;

FIG. 11 is a simplified side view of a further embodiment of theinvention being fed down an esophageal passage of a patient;

FIG. 12 is a partial perspective side view in cross-section of anotherdevice according to an embodiment of the invention;

FIG. 13 is another perspective side view in cross-section of anotherdevice embodiment of the invention;

FIG. 14 is a cross-sectional view showing a pulley assembly according toan embodiment of the invention;

FIG. 15 is a transverse cross-sectional view of a device according to anembodiment of the invention;

FIG. 16 is a perspective side view of an alternative arm according to afurther embodiment of the invention which may be employed in the deviceof FIGS. 3 and 4 shown in a bent configuration; and

FIG. 17 is a perspective side view of the arm of FIG. 16 shown in asubstantially straight configuration.

DETAILED DESCRIPTION

FIG. 1 is a front cross-sectional view of theesophageal-gastro-intestinal tract 40 from a lower portion of theesophagus 41 to the duodenum 42. The stomach 43 is characterized by thegreater curvature 44 on the anatomical left side and the lessercurvature 45 on the anatomical right side. The tissue of the outersurfaces of those curvatures is referred to in the art as serosa tissue.As will be seen subsequently, the nature of the serosa tissue is used toadvantage for its ability to bond to like serosa tissue. The fundus 46of the greater curvature 44 forms the superior portion of the stomach43, and traps gas and air bubbles for burping. The esophageal tract 41enters the stomach 43 at an esophageal orifice below the superiorportion of the fundus 46, forming a cardiac notch 47 and an acute anglewith respect to the fundus 46 known as the Angle of His 57. The loweresophageal sphincter (LES) 48 is a discriminating sphincter able todistinguish between burping gas, liquids, and solids, and works inconjunction with the fundus 46 to burp. The gastroesophageal flap valve(GEFV) 49 includes a moveable portion and an opposing more stationaryportion. The moveable portion of the GEFV 49 is an approximately 180°,semicircular, gastroesophageal flap 50 (alternatively referred to as a“normal moveable flap” or “moveable flap”) formed of tissue at theintersection between the esophagus 41 and the stomach 43. The opposingmore stationary portion of the GEFV 49 comprises a portion of the lessercurvature 45 of the stomach 43 adjacent to its junction with theesophagus 41. The gastroesophageal flap 50 of the GEFV 49 principallycomprises tissue adjacent to the fundus 46 portion of the stomach 43, isabout 4 to 5 cm long (51) at it longest portion, and the length maytaper at its anterior and posterior ends. The gastroesophageal flap 50is partially held against the lesser curvature 45 portion of the stomach43 by the pressure differential between the stomach 43 and the thorax,and partially by the resiliency and the anatomical structure of the GEFV49, thus providing the valving function. The GEFV 49 is similar to aflutter valve, with the gastroesophageal flap 50 being flexible andcloseable against the other more stationary side.

The esophageal tract is controlled by an upper esophageal sphincter(UES) in the neck near the mouth for swallowing, and by the LES 48 andthe GEFV 49 at the stomach. The normal anti-reflux barrier is primarilyformed by the LES 48 and the GEFV 49 acting in concert to allow food andliquid to enter the stomach, and to considerably resist reflux ofstomach contents into the esophagus 41 past the gastroesophageal tissuejunction 52. Tissue aboral of the gastroesophageal tissue junction 52 isgenerally considered part of the stomach because the tissue protectedfrom stomach acid by its own protective mechanisms. Tissue oral of thegastroesophageal junction 52 is generally considered part of theesophagus and it is not protected from injury by prolonged exposure tostomach acid. At the gastroesophageal junction 52, the juncture of thestomach and esophageal tissues form a zigzag line, which is sometimesreferred to as the “Z-line.” For the purposes of these specifications,including the claims, “stomach” means the tissue aboral of thegastroesophageal junction 52.

FIG. 2 is a front cross-sectional view of anesophageal-gastro-intestinal tract illustrating a Grade I normalappearance movable flap 50 of the GEFV 49 (shown in dashed lines) and adeteriorated Grade III gastroesophageal flap 55 of the GEFV 49 (shown insolid lines). As previously mentioned, a principal reason forregurgitation associated with GERD is the mechanical failure of thedeteriorated (or reflux appearance) gastroesophageal flap 55 of the GEFV49 to close and seal against the higher pressure in the stomach. Due toreasons including lifestyle, a Grade I normal gastroesophageal flap 50of the GEFV 49 may deteriorate into a Grade III deterioratedgastroesophageal flap 55. The anatomical results of the deteriorationinclude moving a portion of the esophagus 41 that includes thegastroesophageal junction 52 and LES 48 toward the mouth, straighteningof the cardiac notch 47, and increasing the Angle of His 57. Thiseffectively reshapes the anatomy aboral of the gastroesophageal junction52 and forms a flattened fundus 56. The deteriorated gastroesophagealflap 55 illustrates a gastroesophageal flap valve 49 and cardiac notch47 that have both significantly degraded. Dr. Hill and colleaguesdeveloped a grading system to describe the appearance of the GEFV andthe likelihood that a patient will experience chronic acid reflux. L. D.Hill, et al., The gastroesophageal flap valve: in vitro and in vivoobservations, Gastrointestinal Endoscopy 1996:44:541-547. Under Dr.Hill's grading system, the normal movable flap 50 of the GEFV 49illustrates a Grade I flap valve that is the least likely to experiencereflux. The deteriorated gastroesophageal flap 55 of the GEFV 49illustrates a Grade III (almost Grade IV) flap valve. A Grade IV flapvalve is the most likely to experience reflux. Grades II and III reflectintermediate grades of deterioration and, as in the case of III, a highlikelihood of experiencing reflux. With the deteriorated GEFVrepresented by deteriorated gastroesophageal flap 55 and the fundus 46moved inferior, the stomach contents are presented a funnel-like openingdirecting the contents into the esophagus 41 and the greatest likelihoodof experiencing reflux. Disclosed subsequently is a device for restoringthe normal gastroesophageal flap valve anatomy, which device is oneembodiment of the present invention.

Referring now to FIG. 3, it illustrates a device 100 embodying thepresent invention being fed through the mouth 60, throat 62, andesophagus 41 of a patient 110. The side view illustrated in FIG. 3illustrates the obstacles involved in feeding a transoralgastroesophageal flap valve restoration device into the stomach throughthe esophageal passage including the mouth 60, throat 62, and esophagus41. As may be noted in FIG. 3, the back of the throat makes a 90° turnin the esophageal passage. The radius of that turn, in most adultpatients, will be on the order of 44 mm. The length of the arc of the90° turn is on the order of 6.75 cm. The diameter of the throat is onthe order of 2 cm. The esophageal passageway to the stomach maintains ormay be able to maintain a diameter of 2 cm. As a result, a device to befed through the mouth, and down the throat and esophagus must have amaximum transverse perimeter on the order of 6.28 cm (2 cm×π) or less.

In addition to the restraints on the maximum transverse perimeter, thedevice must be able to negotiate the 90° turn in the back of the throat.Still further, in order to restore a gastroesophageal flap valve, theflap must be of sufficient length so as to close the esophagus. Hence,the fold is preferably, for example, 3 cm in length or greater. In orderto form a fold of 3 cm or greater, a device having a length of 6 cm orgreater would be required. Obviously, a rigid device 6 cm in lengthwould have a difficult time in negotiating the 90° turn in the back ofthe throat.

Accordingly, the gastroesophageal flap valve restoration devicesdisclosed herein representing various embodiments of the presentinvention are capable of navigating the 90° turn in the back of thethroat without damaging mouth, throat, or esophageal tissue. As will beseen here in each of the embodiments, the devices are dimensioned tofollow the esophageal path and configured to flex in a direction tofollow the esophageal path while also being configured to besubstantially rigid when necessary in forming a restored flap of agastroesophageal flap valve.

The device 100 according to one embodiment of the present invention isshown in FIG. 4. The device 100 is carried by a longitudinal member 114which feeds the device 100 down the esophageal passage into the stomach.The device 100 includes a first member or body 116 and a second memberor arm 118.

The arm 118 is hingedly coupled to the body 116 by a pulley 120. As aresult, the arm 118 is arranged for reciprocal movement with respect tothe body 116. When the device 100 is being fed down the esophagealpassage, the arm 118 may be rendered to be substantially inline with thebody 116 as may be seen in FIG. 3.

To render the body 116 flexible for bending around the 90° turn in theback of the throat as illustrated in FIG. 3, the body 116 includes aplurality of slots comprising a first plurality of slots 122 and asecond plurality of slots 124. The first plurality of slots 122 arewider in dimension than the second plurality of slots 124. As a result,the body 116 is capable of bending as illustrated in FIG. 3 fornegotiating the 90° turn in the back of the throat.

To lend further flexibility to the device 100, the arm 118 is alsorendered flexible during the passage down the esophageal passageway. Tothat end, it will be noted in FIG. 5 that the arm 118 has an arcuatecross-section 126. The concave side of the arm 118 is adjacent the firstplurality of slots 122 when the arm 118 is in a substantially closedposition as illustrated in FIG. 4. The arcuate cross-section 126 rendersthe arm 118 substantially rigid with respect to forces applied to thearm 118 in a direction 130 against the concave side of the arcuateconfiguration 126. However, the arm 118 will be substantially flexibleto forces applied in direction 132 substantially opposite that ofdirection 130. The effect on the arcuate configuration 126 by forcesapplied in the direction 132 may be seen in FIG. 6. The forces appliedin the direction 132 will tend to flex the arm 118 and widen the arcuateconfiguration 126. Hence, the arm 118 imposes a greater resistance toforces applied in direction 130 than to forces applied in direction 132.Hence, as may be noted in FIG. 3, forces applied to the arm 118 as itnegotiates the 90° turn will be in the general direction of thedirection 132. As a result, the arm 118 is also capable of flexing forfollowing the esophageal passageway through the throat 62 and down theesophagus 41.

Referring now to FIG. 7, it will be seen that the device 100 has beenfed down the esophagus 41 to a position aboral of the gastroesophagealjunction or Z-line 52. Stomach tissue 43 has been pulled into the deviceby a tissue puller 128. Further, the arm 118 has been closed relative tothe body 116 to receive the stomach tissue 43 to receive stomach tissue43 between the body 116 and the arm 118. The body 116 and arm 118 alongwith the tissue puller 128 creates a fold 70 of stomach tissue 43 aboralof the Z-line 52. Once fasteners (not shown) are driven through the fold43, the fold is maintained to form a restored gastroesophageal flapvalve when the device 100 is removed from the stomach. Suitablefasteners and stomach pullers are described, for example, in co-pendingU.S. patent application Ser. No. 10/783,717, filed Feb. 20, 2004, forTISSUE FIXATION DEVICES AND A TRANSORAL ENDOSCOPIC GASTROESOPHAGEAL FLAPVALVE RESTORATION DEVICE AND ASSEMBLY USING SAME, which application isassigned to the assignee of the present invention and incorporatedherein in its entirety.

While forming the flap 70 in the stomach tissue 43, the device 100 isrendered substantially rigid. The rigidity of the device is provided byrigidity in both the body 116 and the arm 118. More specifically,because the second set of slots 124 are relatively narrow, they willclose when the body 116 is straightened by forces applied to it by thestomach tissue folding process and by a compression assembly to bedescribed hereinafter.

As will also be described hereinafter, the pulley 120 is a single pulleyof sufficient diameter to provide a mechanical advantage enclosing arm118 on the body 116 to enable the stomach tissue 43 to be folded intothe flap 70. A pulley of such dimension is rendered possible by a singlehinged connection of the arm 118 to the body 116 by the pulley 120. Thiswill be seen more particularly hereinafter.

Referring now to FIG. 8, it is a plan view of the tip end 119 of the arm118 according to a further embodiment of the present invention. Here, itmay be seen that the arm has a longitudinal dimension 140 and atransverse dimension 142. To render the device of further reduceddimension during passage through the esophageal passage, it will benoted in FIG. 8 that the tip end 119 of the arm 118 includes a hinge121. The hinge 121 may be a living hinge, for example, but other formsof hinge structures may also be employed. The hinge 121 permittedfolding of the tip end 119 to reduce the transverse dimension 142 of thetip end 119 of the arm 118.

Referring now to FIG. 9, it shows another embodiment of the presentinvention. The device of FIG. 9, denoted by reference character 150,like device 100, includes a body 156 and an arm 158. The arm 158 ishingedly coupled to the body 156 by, for example, a pulley 170. As willbe noted in FIG. 9, the body 156 also includes a first plurality ofslots 172 and a second plurality of slots 174. The first plurality ofslots 172, as in the previous embodiment, are wider then the secondplurality of slots 174. The slots 172 and 174 render the body 156flexible during esophageal passage into the stomach of the device 150and rigidity of the body 156 during restoration of a gastroesophagealflap valve. The arm 158 is also flexible during esophageal passage ofthe device 150 but rigid during the formation of a restoredgastroesophageal flap valve. To that end, it will be noted that the arm158 comprises a plurality of links 160, 162, and 164. Link 160 ishingedly coupled to the body 156 at the pulley 170, and is also hingedlycoupled to link 162 by a hinge 161. The hinge includes a pin 163confined within a slot 165 which limits the pivotal movement betweenlink 160 and link 162.As shown in FIGS. 9 and 11, the arm 158 ispositioned radially outwardly relative to the outer tubular surface ofthe elongated member 150, and is pivotable 180° relative to theelongated tubular member 150.

Similarly, link 164 is hingedly coupled to link 162 by another hinge167. It also includes a pin 169 which limits the pivotal movementbetween the link 164 and the link 162.

When the device 150 is in the process of forming a restoredgastroesophageal flap valve, the links 160, 162, and 164 are locked soas to be substantially inline as shown in FIG. 9. However, when thedevice 150 is fed down the esophageal passage, the hinges 161, and 167,and the pulley 170, permit the arm 158 to be flexible and conform to thepath of the esophageal passage as a device 150 passes through the throatfrom the mouth to the esophagus. Once the device 150 is within thestomach and forming a flap as generally shown, for example, in FIG. 7,the links 160, 162, and 164 will be locked so as to be rigid for formingthe fold in the stomach tissue. With further reference to FIG. 9, thedistal end 270 of the arm 158 is widened to form wing members 278 topermit broad surface contact with the stomach tissue as thegastroesophageal flap is restored. This wing member 278 alsoaccommodates openings 272 and 274. The openings 272 and 274 providetissue reinforcement as fasteners are driven through the restoredgastroesophageal flap in tissue areas defined by the openings 272 and274.

FIG. 10 is a perspective view of the device of FIG. 3 while restoring agastroesophageal flap valve. Here it may be noted that the flap 70 hasbeen formed by the body 116 and arm 118. A fastener 72 has been deployedto maintain the flap 70.

As will also be noted in FIG. 10, the device 100 permits an endoscope102 to pass through the body 116 to permit the procedure to be viewed bythe medical personnel. As will be seen hereinafter, the device 100allows the endoscope 102 to be passed there through while maintaining arestricted transverse maximum perimeter to permit the device 100 to befed down the esophageal passageway into the stomach. As will also benoted in FIG. 10, the fold 70 is being restored aboral of the Z-line 52.

FIG. 11 illustrates another embodiment of the invention. Again, thedevice 100 is being fed down the back of the throat 62 of the patient110. The device 100 includes a flexible sheath 101 overlying at leastthe body 116 of the device 100. The sheath 101 protects the tissueforming the lining of the esophageal passage from any edges which mayresult from the plurality of slots within the body 116. In addition, oralternatively, the slots may be filled with a flexible filler 103 topresent a uniform surface of the body 116 to the tissues lining theesophageal passage. Preferably, the filler material 103 is more flexiblethan the plastic or other material forming the body 116 and thus has alower durometer than the material forming the body 116.

Referring now to FIG. 12, it is a partial perspective side view ofanother device 100A illustrating a further embodiment of the presentinvention. In accordance with this embodiment, the body 116 of thedevice 100A includes the pulley 120 and a control cable 182. The controlcable 182 is at least partially wrapped around the pulley 120 to form apair of control extensions 184 and 186. The control extensions 184 and186 are confined within guide tubes 188 and 190 respectively which serveto maintain the cable under tension. It will also be noted that thecable 182 and its control extensions 184 and 186 extend along thelongitudinal dimension 192 of the body 116 adjacent to the second andnarrower set of slots 124.

When a force 198 is imparted to the control cable 182 to pivot arm 118pivots for forming the stomach tissue flap. The arm 118 is coupled tothe body 116 by a single hinge 123 formed by the pulley 120.

Referring now to FIG. 13, it is a partial perspective side view incross-section of a further device 100A illustrating a further embodimentof the present invention. In accordance with this embodiment, the body116 of the device 100B includes a compression assembly 180 whichselectively renders the body substantially rigid. The compressionassembly 180 includes the pulley 120 and the control cable 182. Again,the control cable 182 is at least partially wrapped around the pulley120 to form a pair of control extensions 184 and 186. The controlextensions 184 and 186 are confined within guide tubes 188 and 190respectively. It will also be noted that the cable 182 and its controlextensions 184 and 186 extend along the longitudinal dimension 192 ofthe body 116 adjacent to the second and narrower set of slots 124. Theguide tubes 188 and 190 abut against stop 196.

When the device is fed down the esophageal passageway, the body 116 isflexible and non-compressed. However, when the device 100B is within thestomach aboral of the Z-line and ready to be used for forming a restoredgastroesophageal flap valve, the device is rendered substantially rigid.When a force 198 is imparted to the control cable 180 to pivot arm 118for forming the stomach tissue fold, the body 116 of the device 100 isalso placed under compression from the pulley 120 to the stops 196 toensure closing of the narrow slots 124 and promote rigidity of the body116 of the device 100B.

As also may be noted in FIG. 13, the arm 118 is coupled to the body 116by a single hinge 123 thus requiring only a single pulley 120. Thissingle hinge 128 may be more readily seen in FIG. 14.

As may be seen in FIG. 14, the arm 118, the body 116, and the pulley 120are held together by a pivot pin 200. The arm 118, pulley 120, and body116 are held together on the pivot pin 200 by a locking pin 202.

As may be further noted in FIG. 14, the arm 118 includes a slot 204which is received by flanges 206 and 208 of the pulley 120. The flangesextend substantially parallel to each other across the surface 210 ofthe pulley 120. The slot 204 of the arm 118 is also received by thepivot pin 200 as shown.

The foregoing structure allows the connection of the arm 118 and thebody 116 to be dismantled if necessary. The dismantling of theconnection between the arm 118 and the body 116 may be effected bysimply pulling the locking pin 220.

Referring now to FIG. 15, it shows a cross-section of the device 100illustrating its maximum transverse perimeter 220. In FIG. 15, it willbe noted that the body 116 includes a passageway 222 to permit theendoscope 102 to pass there through. The passageway 222 may have adiameter of, for example, 11 mm.

Also illustrated in FIG. 15 is the pulley 120. Because only one hingedconnection utilized between the arm 118 and body 116, a single pulley isrequired. Since a single pulley is required, the pulley 120 may have adiameter 224 sufficient to provide a mechanical advantage for impartingreciprocating movement to the arm 118 relative to the body 116 throughthe pulling of the control cable 182. Hence, even though the device 100makes provision for an endo scope 102 to be passed there through and apulley 120 of sufficient diameter to provide a mechanical advantage foroperating the arm 118, the device 100 is still able to maintain amaximum perimeter 220 which is no greater than, about, 6.28 cm. Hence,the device has a small enough maximum transverse perimeter to be passeddown the esophageal passage including the mouth 60, throat 62, andesophagus 41 (FIG. 3) of a patient.

To provide a sufficient mechanical advantage the pulley 120 may have adiameter greater than about 7 mm. Preferably, the pulley has a diameterof about 10 mm.

Referring now to FIGS. 16 and 17, they show another arm 218 according toan embodiment of the present invention which may be employed in thedevice 100 of FIGS. 3 and 4. The arm 218 may be hingedly coupled to thebody 116 by a slot 230 which may slide over the flanges 206 and 208 ofthe pulley 120 (FIG. 14).

The arm 218 is configured to be flexible during esophageal passage intothe stomach of the device 100 and rigid during restoration of agastroesophageal flap valve. To that end, it will be noted that the arm218 comprises a plurality of links 260, 262, and 264. Link 260 may behingedly coupled to the body 116 at the pulley 120, and is also hingedlycoupled to link 262 by a hinge 261. The hinge 261 includes a pin 263.Similarly, link 264 is hingedly coupled to link 262 by another hinge267. It also includes a pin 269.

When the device 100 is fed down the esophageal passage, the hinges 261,and 267, and the pulley 120, permit the arm 218 to be flexible and bentas shown in FIG. 16 to conform to the path of the esophageal passage asthe device 100 passes through the throat from the mouth to theesophagus. Once the device 100 is within the stomach and forming agastroesophageal flap, the links 260, 262, and 264 will be locked torender the arm 218 rigid and substantially straight for forming the foldin the stomach tissue as shown in FIG. 17.

With further reference to FIGS. 16 and 17, it may be noted that thedistal end 270 of the arm 218 includes a center slit 276 and is widenedto permit broad surface contact with the stomach tissue as thegastroesophageal flap is restored. This widening also accommodatesopenings 272 and 274. The openings 272 and 274 provide tissuereinforcement as fasteners are driven through the restoredgastroesophageal flap in tissue areas defined by the openings 272 and274.

In view of the widened nature of the distal end 270 of the arm 218, thedistal end 270 is preferably comprised of a flexible material which ispreformed in a somewhat closed arcuate configuration to reduce thedistal end cross-section for passage through the esophageal passage.However, due to the flexible nature of the material used to form the arm218, and the central slit 276, the wings 278 and 280 formed by the slit276 will readily fan out and make broad contact with the tissue when thetissue is contacted for forming the gastroesophageal flap.

While particular embodiments of the present invention have been shownand described, modifications may be made, and it is therefore intendedin the appended claims to cover all such changes and modifications whichfall within the true spirit and scope of the invention.

What is claimed is:
 1. An assembly for restoring a gastroesophageal flapvalve, comprising: a longitudinal member having an end arranged forplacement in a stomach; a transoral gastroesophageal flap valverestoration device carried at the end of the longitudinal member andincluding an elongated body member, and an arm member hingedly coupledto the elongated body member, the elongated body member and arm memberbeing arranged for esophageal passage into a stomach to receive stomachtissue there between to form a flap of a gastroesophageal flap valve;the elongated body member having a longitudinal tubular dimension andincludes an outer tubular surface; the arm member being attached to theelongated body member by a hinge and pulley, the arm member beingpositioned radially outwardly relative to the outer tubular surface ofthe elongated body member and pivotable 180° relative to the elongatedbody member; the arm member having a distal end with a wing memberextending transverse to a longitudinal axis of the arm member, the wingmember having spaced apart openings to provide tissue reinforcement asfasteners are driven through the flap in tissue areas defined by theopenings; and the elongated body member and arm member being configuredto flex in a direction to follow an esophageal path into the stomach andto be rigid when receiving the stomach tissue there between and formingthe flap of the gastroesophageal flap valve.
 2. The assembly of claim 1,wherein each of elongated body member and the arm member have a lengthgreater than three centimeters.
 3. The assembly of claim 1, wherein eachof elongated body member and the arm member have a length between threeand five centimeters.
 4. The assembly of claim 1, wherein the elongatedbody member and the arm member are arranged to be longitudinally alignedwith each other when in the esophageal passage.
 5. The assembly of claim1, wherein at least one of the elongated body member and the arm memberhave an arcuate cross section.
 6. The assembly of claim 5, wherein boththe elongated body member and the arm member have an arcuate crosssection.
 7. The assembly of claim 1, further comprising, a flexiblesheath overlying the elongated body member.
 8. The assembly of claim 1wherein a plurality of slots comprises a first set of slots and a secondset of slots, the first and second sets of slots being juxtaposed, andthe slots of the first set of slots being wider than the slots of thesecond set of slots.
 9. The device of claim 1 wherein one of the firstand second members comprises a plurality of links and a plurality ofhinges hingedly coupling the links together.
 10. The device of claim 9wherein the hinges are arranged for limited pivotal movement to renderthe one of the first and second members substantially rigid.
 11. Thedevice of claim 10 wherein the elongated body member includes aplurality of transverse slots and the arm member includes the pluralityof links.
 12. The device of claim 1 wherein the arm member is distal tothe elongated body member, wherein the arm member has a longitudinaldimension, a transverse dimension, and a tip end, and wherein the tipend of the arm member includes a hinge to permit folding of the tip endto reduce the transverse dimension of the arm member tip end.